Manual Double Check Emergency Faith-based Prescriptions Identity Cards Questions Emergency VIsion Services Show ID Important More Community Organization Trade Associations Women’s Health Online Carry ID Dental Phone Fill Out Form / Notes Transportation Long Term Care Skilled Services Form 1301 International Parkway Suite 400 Fax to 1-855-266-5275
Manual. Double Check. Emergency. Faith-based. Prescriptions. Identity. Cards. Questions. VIsion. Emergency. Services. Show ID. Important. More. Community.
PRIMARY ICON EXAMPLES Long Term Care Skilled Services Form Medical Emergency VIsion Dental Behavioral Hearing Services Services Health Fax to 1-855-266-5275 1301 International Parkway Suite 400 Sunrise, FL 33323 1-877-211-1999 Monday through Friday 8am 5pm PlWeoamseen'sfax thPriessccrioptmionpsleted Ofonlrinme along wPhiotnhe assocFiiall tOeutdFocrmlin/ icaTlriannsfpoorrtmatiaontion or medical records to Sunshine Health Notes Health. Lack of clinical information may result in delayed determination. *Indicates Required Field *Member First Name: Provider Identity *MMeamnubaelr ID #: Cards *Member Home Address: *Member Phone Number: Double Check Questions Show ID Important MSMemALbLeIrCOHNeiEgXhAtM(iPnLEinSches): mPhoNneew RequestPremscriEptxitoennsionBReheaqvuioeraslt Health Requesting Provider NPI: Member Information Carry ID *Member Last Name: Emergency Faith-based *Member Date of Birth: *Service Address (if different from home): Alternative Contact Person: More OCrogmanmizuanRtiiteoynlationsAhsispTorctaioadteMionesmber: Alternative Contact Phone Number: Member Weight (in pounds): Requesting Provider Information Web Date member last seen by requesting provider: Requesting Provider TIN: *Requesting Provider Name: COLOR *Phone Number: m Check here if this request is related to an inpatient discharge. Raspberry Requesting Provider Contact Name: *Fax Number: Authorization Request *If a Discharge, Date of Discharge: RFeavecrisleity Name: *Primary Diagnosis Code: Additional Diagnosis Code: Number of Total Units/Visits/Days Requested: 23 *Start Date of Service: End Date of Service: Information on services that require a prior authorization can be found at www.SunshineHealth.com. For questions please call Sunshine Health's Utilization Management Department at 1-877-211-1999 and select the prompt for home care or DME. We are open from 8 a.m. to 5 p.m. Monday through Friday. Last Updated 3/23/2017 SunshineHealth.com © 2017 Sunshine State Health Plan. All rights reserved. Long Term Care Skilled Services Form *Member First Name: *Member Last Name: *Member ID Number: *Member Date of Birth: Home Health m Skilled Nurse m LPN m Occupational Therapy m Physical Therapy m Respiratory Therapy m Speech Therapy m Wound Care *HCPC Code: Description: *Requested Services Oxygen/Respiratory Equipment Liter Flow Per Minute: Route: m Nasal Cannula m Simple Mask m Other: Hours of Use: m Continuous m With Exertion m Hours of Sleep m Bleed into CPAP/BiPAP m Other Delivery Device: m Concentrator m Portable Cylinders m Conserving Device m Liquid Helios Portable m Other: Date of Saturation Test: Oxygen Saturation of PO2 Results: m Apnea Monitor m BiPAP m CPAP m Nebulizer m Vent Durable Medical Equipment Special Consideration: Length of Need: Additional information: Physician Attestation and Signature I certify that I am the treating physician identified in this form and that I have ordered the noted services. Physician Signature: Date: Physician's Printed Name: Information on services that require a prior authorization can be found at www.SunshineHealth.com. For questions please call Sunshine Health's Utilization Management Department at 1-877-211-1999 and select the prompt for home care or DME. We are open from 8 a.m. to 5 p.m. Monday through Friday. Last Updated 3/23/2017 SunshineHealth.com © 2017 Sunshine State Health Plan. All rights reserved.Adobe PDF Library 15.0